She looked her age — 27, startlingly close to my own age. Did we share acquaintances or friends of friends? She fixed her hair in a ponytail and wore jeans and a collared shirt with a sweater, a preppy and youthful fashion statement consistent with her budding career as an architect. Polite but slightly withdrawn she looked uncomfortable, out of place. And indeed she was. No one had ever been sick in her immediate family. The hospital felt strange. She exercised daily and strictly adhered to a diet of fruits, vegetables, and fish. Why did she need to be here? Her boyfriend, with her at the time, was similarly accomplished and self-disciplined. The trajectory of their lives together stretched on ad infinitum.
One week prior to her hospitalization, she experienced diplopia, or double vision. When she looked straight ahead, objects appeared normal, but if she looked to the right they underwent binary fission. At first she thought nothing of it, but it persisted. Her vision was her livelihood. Her work depended on absorbing sketches, drawings, and visual plans. So she came to the hospital.
On my exam I noticed only one abnormality: Her right eye would not abduct. When our eyes look in one direction or another they ought to move together. Because of this intricate biological design, when we look in any direction, images align as if we are seeing everything with one eye. In this patient’s case, a lesion damaged the nerve (abducens nerve) for the muscle moving the right eye laterally. We ordered an MRI of her brain to look for a cause.
In her brainstem sat a brain tumor called a glioma. The prognosis was poor, maybe a couple of years. But it wasn’t just the limit on her life that was the issue. As these tumors grow they wreak absolute havoc on their victims. Patients develop weakness, vision loss, and headaches. They require wheelchairs to get around. And all this occurs in a step-wise fashion, often with preserved cognition such that the patient is ensured the maximal amount of suffering with the maximum amount of awareness.
She knew none of this when we finally sat her down to tell her. But she needed to know. And so we broke the news. The whole scene is a bit of a haze. I can’t remember the exact details of what was said but I do remember her tears and the question she asked us through them: “Will I ever see thirty?”
In 2014, Dr. Atul Gawande, a Harvard physician and writer, penned Being Mortal, a book about the last stages of life and the financial, sociological, and ethical implications of how we, as physicians and as patients, deal with these final moments. In one particularly striking part of the book, Gawande discusses what makes life worth living when we are old, frail, and disabled. From the perspective of the young and healthy, we fear that life and its pleasures will end when we can’t run or multitask or drive or engage as visibly with the world around us. We fear being unhappy when time inevitably snatches our youth away.
Laura Carstensen, a professor of psychology at Stanford, studied this question: Do people grow unhappier as they age? Between 1993 and 2005, Castensen and others involved with the study tracked 180 Americans between the ages of 18 and 94. Every five years, the subjects were given pagers and were randomly paged for a one-week period. They immediately responded to questions regarding their happiness, satisfaction and comfort. Carstensen found that, in fact, people grow happier as they age. As she stated,
As people get older, they’re more aware of mortality. So when they see or experience moments of wonderful things, that often comes with the realization that life is fragile and will come to an end. But that’s a good thing. It’s a signal of strong emotional health and balance.
Other studies since then have reinforced these findings. But does this really have to do solely with age or is there something more at play here? “Suppose,” Gawande writes, “it merely has to do with perspective — your personal sense of how finite your time in this world is.”
He continues,
When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow’s pyramid — achievement, creativity, and other attributes of ‘self-actualization.’ But as your horizons contract — when you see the future ahead of you as finite and uncertain — your focus shifts to the here and now, to everyday pleasures and the people closest to you.
Carstensen developed multiple experiments in different populations to test this theory. She studied patients with terminal AIDS who were young, and conducted the same studies with people from Hong Kong. When the end is near, regardless of age or cultural background, people value time with their loved ones more. However, when the end is far off, people tend to value time with their loved ones less. Our situation, not our age, gives us a sense of perspective, a sense of either finality or infinitude and consequently changes our priorities and the way we live.
Working in medicine provides this kind of perspective. The hospital collects people facing stygian tragedies and places them directly in our laps. Our minds don’t stray too far before we are once again reminded of the fragility of human life. Becoming a physician and being a physician forces this realization upon us. As such I feel unfortunate and fortunate. I am lucky because I am always reminded of how lucky I actually am, of how sheltered and shielded I have been (thus far) from true tragedy in my own physical life. And I am unlucky because not a day goes by when I do not realize that, despite my age, true tragedy for myself or a loved one may not be far off — that is a sobering thought with a perennial lesson.
In this blog I attempted to share a bit of that perspective, and more. But perspective is due to one’s ability to see the beginning and the end, to look from above and to understand that nothing goes on indefinitely. And so this will be my last post. As my career advances, I recognize that the blog has served its purpose and reached its closing act, though my writing will continue elsewhere.
For what exists here at The New Atlantis there are many people to thank. But there are a few in particular who deserve mention. It was under Adam Keiper, former editor of The New Atlantis and former Books & Arts editor of The Weekly Standard, that this project began. He was receptive to it and encouraging from the very beginning. My writing and thinking benefited greatly from his steady hand. And this blog’s conclusion comes under the similarly steady hand of Ari Schulman, who has been encouraging and receptive to its continuation. He is a true friend and intellectual guide. I have benefited greatly from his edits as well as those of Samuel Matlack and Brendan Foht. A writer and his or her work leans more heavily on great editors than any reader will ever know; this blog has had great editors.
And to you dear reader, I hope the writings herein contributed something to your understanding of medicine, of the life of a physician, of the education of a physician, of medicine’s theoretical, practical, and ethical complexities — and thus also of life itself. I bid you adieu.
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